The promotion and protection of child health has been an expressed basic tenet of the public health profession for many years. Child health is a product of family health so that the implications are broad. The basic tenet, however, rests upon the special vulnerability and dependency of the child, the large increment of disease and disability whose prevention requires action during childhood, and the crucial influence of this period of the life span on the future human resources of society.
As an expressed responsibility for the health of children and those of families rather than for specific categories of disease or environment, child health programs have often existed uneasily and been misunderstood within the field of public health. The traditional public health programs and services of the past have interpreted the broad tenet very narrowly. As an instrument of government, political and bureaucratic constraints forced them to contribute to the fragmentation, duplication, and inefficiency which characterize the entire sector of services that address themselves to human resources. To some extent the public health profession itself compounded the situation by creating myths which deified prevention and then failed to evaluate its own activities with a critical eye.
In recent years, as in the past, the plight of children ravaged by the war we wage, poisoned by the environment we create, or neglected by the health services we support, stands as a concrete symbol of the gap between the promise and behavior of our society. In this position children serve as a nexus and rallying point for the forces of social change. The mass media communicate the signs and symbols of social failure to a far wider extent and with a deeper sense of urgency than has ever been true in the past. Responses have taken the form of some well-documented reports, many proposals for action on behalf of children, and the enactment of occasional uncoordinated pieces of new legislation. Although the concerns themselves are felt nationally, we lack the kind of national consensus that leads to rapid significant change in social values. Such change, and the resulting political action which re-distributes power and privilege according to the priorities of a different value system, is required in order to meet the needs of our children and to close the gap between the promise and behavior of our society.
In this atmosphere of disunity and discontent there is a double danger. On the one hand, the plight of children may be exploited (as it has in the past) on behalf of narrow limited programs offered in order to divert pressures for broader change but leading in effect to further fragmentation of health and social services. On the other hand, there is a danger that the special needs of children will be dismissed as exaggerated sentimentalities and ignored in legislation directed toward rationalizing the total health system itself through cost reductions and attempts to overcome inefficiencies.
It is difficult to determine whether or not the promotion and protection of child health is a major goal of public policy in the United States. However, it is quite evident that such a policy, though voiced from time to time by political leaders, has not in fact been implemented by political and legislative action.
Within our population there are striking group differences in perinatal and infant death rates and in the disease-specific morbidity and mortality which make them up. These differences are not the product of group genetic heritage. They are correlated closely with group differences in the physical environment in which children grow, the quality of their life as a member of a family and a community, and the quality of the child health and child care services to which they have access. In this sense the excess death, disease and debility among children born to urban or rural slum parents are the products of society itself. The relative contribution to this excess toll of an inferior environment on the one hand and inferior and insufficient services on the other hand is an academic question from the standpoint of public policy and action. It is clear from the information we already possess that both deficiencies contribute independently to excess death and disease. It is equally clear that no one of these negative influences upon child health can be eliminated without dealing simultaneously with the others.
During the past two decades we have also learned that children born to disadvantaged parents are far more vulnerable to relatively common diseases and poorly defined conditions such as perinatal stress, whose effects children born to more fortunate parents can overcome in the course of their growth.
These insults apparently act in concert with a growth retarding environment to create permanent functional handicaps. The differential group outcomes of such insults indicate first that the unfavorable outcomes are preventable and second that action programs must direct special efforts to children of disadvantaged groups who are at greatest continuing risk. These are also the groups that are least easy to reach with the service distribution systems presently in operation.
The genesis of much adult disease, perhaps the length of the life span itself, may be influenced by the environment in which children are reared and the services to which they have access. Some of these relationships remain speculative. For others, such as the poorly understood capacity of adult women to bear healthy children, there is no doubt about a causal relationship. Pregnancy outcomes are directly related to the quality of the environment in which the prospective mother herself was reared, irrespective of all the other variables known to influence such outcomes.
Not all children are endowed with the same genetic heritage. Some diseases of genetic origin such as the lipidoses and hemoglobinopathies are linked to ethnicity. Many more diseases have no such links. In contrast to physical endowment, mental endowment is randomly distributed among ethnic groups. Child or adult performance is linked to differences in child-rearing milieus and through this mechanism the cyclic effects of poverty perpetuate themselves.
Children with significant organic handicaps, whether of genetic or post-conceptional origin, face special problems in coping successfully with their environment during growth in order to achieve their full potential as adults. They and their families are in need of special supportive help and education as they grow. The extent of this help varies directly with the physical and social environment in which their birth has placed them.
Although infectious diseases continue to take a higher toll among underprivileged children than among those more fortunately born, the principal causes of excess death and disability among the former group cannot be meaningfully described in terms of conventional disease nomenclature. We are forced to utilize descriptive rather than etiologic terminology, labels such as: low birth weight, accidents, crib death, failure to thrive, brain damage, deviant or delinquent behavior, learning disabilities, etc. The occurrence of these conditions cuts across social classes and is not limited to any one segment of the population. However, their incidence, relatively speaking, is much higher among the disadvantaged than among the more affluent because of the handicaps added by the environment. The challenge of prevention by application of what is already known resides in differential incidence rather than exact cause of these conditions.
The physical environment which surrounds the child is only a part of the exogenous influences which help promote or retard his healthy growth. If this environment contains interior lead paint and rickety stairways, provides no space to store drugs beyond toddler reach, sleeps four and five persons in an unventilated room, offers poor washing facilities but good breeding places for rats and lice, the hazards are obvious. If there is insufficient money to buy the food a child needs, the hazard is equally obvious. Healthy growth under these circumstances is unusual but not impossible.
A second aspect of the child's environment which can be categorized only by such a general term as parental nuturing capacity also influences his healthy growth. This parental capacity (which rests on the possession of knowledge and self-respect) can in turn be sapped away by poor housing and nutrition, social ostracism and discrimination, unemployment and poverty, so that it is only the unusual parent and child who survive unscathed.
Implications for Action
Because it is humanly impossible to remain untouched by the figure of a neglected, crippled, or starving child, and because the relationship of excess child death and debility to disadvantaged social groups is easily observable, all opposition to major social and political action on behalf of the disadvantaged is directed toward the feasibility and effectiveness of a proposal rather than its motivation. These are legitimate concerns, but generally those who express them most strongly are those who have most to gain by maintaining the status quo. Their arguments tend to take one of the following forms:p
- "As much as can be done is already being done. The poor will always be with us." This is a doctrine analogous to original sin and in direct contradiction to both the history and the ethic of America.
- "The financial, technological and manpower resources to implement the program are lacking." This is a strange argument in the face of the efforts the nation has made to place men on the moon and to wage costly war without apparent purpose. The resources exist or can be mobilized if the commitment to do so exists.
- The third set of arguments are more subtle. They direct themselves to the specific nature of a proposed action. If the action is aimed at strengthening health, educational or counseling services, the argument will play up poverty as the main issue and play down the need for government support of personal services. If the action is to strengthen and expand child care services, the argument plays up the need to strengthen family life and advances the claim that child care services are a potential disrupter of the family. If the action is intended to provide jobs or housing or ameliorate poverty more directly, the argument plays up the need for personal services and education and inveighs against government interference with the free market system. If the proposal includes a new agency structure for a new program, the argument states that the existing bureaucracy should be strengthened and given the new responsibility. If the proposal adds new program responsibilities to existing bureaucratic structure, the argument states that a new structure (getting rid of the old deadwood of reorganizing the hierarchy) is the proper approach.
The first three of these ploys are clearly symptoms of a deeper resistance to any change at all. All the evidence available indicates that society must act to alter the poverty environment which it has created while at the same time acting to strengthen parental self-esteem and nurturing capacity and reaching out to insure that comprehensive child health and care services cover targeted disadvantaged populations. Far from disrupting family life, the evidence indicates that child care services of acceptable quality strengthen family life by involving parents in decision-making, increasing their knowledge and self-esteem and thus bringing them closer to their children.
There is every reason to believe that these different types of action, far from being mutually exclusive, are interdependent. All must be implemented in an integrated operation for any one of them to have maximum impact. In our society there are no examples of such efforts because the various forms of action have never been implemented in an integrated fashion.
The second set of arguments, which direct themselves to bureaucratic structure, are more difficult to answer. Our crowded, complex, technologically burgeoning pluralism is set in a society where personal values and goals are diffuse and changing. It can be mobilized for efficient purposeful direct action only in the face of some threat that is clearly perceived by all of its members. Neither altruism nor the plight of some of its children provide sufficient force to mobilize its variety of vested interests. Its struggle to better itself—to apply the American ethic of equal opportunity and individual freedom—is marked by incremental gains and losses rather than rational planning on a long-term basis. In contrast to many of its peer countries in Europe, government service has generally been held in low esteem.Recommended Policy
Such an exposition is not intended to justify an attitude of pessimism and passivity. It is intended to direct attention to political process and strategies to influence change. The specifics of such change can be found in prior statements of the American Public Health Association or follow logically from the preceding portions of this statement.
Since children are influences by virtually every facet of the social and physical environment in which they grow and develop, virtually every action which the nation and its several communities takes or fails to take must be examined on behalf of children. Questions to be asked include:
- In what measurable ways can this action or lack of action be reasonably expected to benefit or harm the growth of children?
- In what feasible ways can the potential benefit of this action to children be enhanced or its potential harm be avoided?
- Are there other feasible efficient ways of achieving the goals of this action which would provide greater benefits or lesser harm to children?
In asking these questions the differential vulnerability during growth of the socially and economically disadvantaged and the outreach participation needed to involve them must be kept in mind.
If the answers to these questions are unknown or uncertain or if there is inaction in the face of obvious need, it is imperative to secure answers to them through study and/or to conceive and execute the action as a pilot trial from which specific practical lessons can be learned.
Social actions at the legislative and bureaucratic level are of two types: those which address themselves directly to the perceived needs of children—such as support of research in child development and health, support of child health and child care services, etc.—and those which address themselves to broad social issues such as income maintenance, federal-state-local relations, employment, housing, or the health care and educational systems. The questions and answers are equally relevant to both types of action or inaction.
The significant issue is how the raising and answering of these questions and communication of the answers to the public at large can be institutionalized within our society in order to have significant impact upon future and social process and social change. The nature of this role has been called Child Advocacy.
The American Public Health Association endorses the concept of Child Advocacy and the institutionalization of this role within our governmental structure. The American Public Health Association is also convinced that the presence and action of Child Advocacy organizations as a parallel structure outside of government are essential as mechanisms to promote change through the democratic process. It endorses proposals to institutionalize such a role in a meaningful way within our governmental structure and the creation and funding of Child Advocacy agencies at state, local, and neighborhood levels.
The exact makeup and bureaucratic positioning of Child Advocacy agencies within government is subject to future discussion. However, the newly created agencies should be endowed with prestige, with an independence from partisan politics, with the staff and funds to document their cases, initiate and execute relevant studies, formulate solutions to problems, communicate effectively with the executive, judicial, and legislative arms of government and with the public at large, and to undertake legal action when indicated.
The lessons of the past make it clear that this kind of ombudsman role cannot be combined with responsibilities for regulating, managing or funding ongoing services. They also make it clear that Coordinating Committees with no power of action of their own or established general Planning Councils, though desirable, are not adequate as responses to the needs of children.
The effectiveness of institutionalizing the concept of Child Advocacy remains to be demonstrated in this country so that wisdom dictates a slow but sure approach to its implementation. Evaluation and study should be carefully built-in to the planning so that the future expansion of the operation will profit from the lessons learned.
The creation and evolution of Child Advocacy agencies within government must never be allowed to delay the many obvious direct and indirect actions which will benefit children. Too often planning and study are synonymous with delaying action. In a society where values and technology are rapidly changing there will always be many questions for which definitive answers are lacking. More often than not answers are obtainable only by initiating the programs on the basis of heuristic reasoning or simple humanitarianism and planning and building into it the mechanisms for obtaining the relevant answers.
Although creation of an agency with direct access and influence upon the executive and legislative branches of all levels of government is one important step toward influencing executive, legislative, judicial, and bureaucratic response to the needs of children, it is even more essential that pressures for such responses be exerted forcefully from outside government. There exists a challenging opportunity for public education and the build-up of a constituency capable of maintaining a sense of outrage and of exerting the pressures required to influence political process. The American Public Health Association pledges itself to exert all possible efforts to meet this challenge by:
- examining and taking positions on legislation and making these positions known and
- assuming a leadership role together with other responsible groups in whatever actions are needed to create and maintain the concept of Child Advocacy as a viable force within our society.
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